The goal of any arthroscopic surgical procedure is to reproduce what is done with its corresponding open procedure. Sometimes this simple tenet can be forgotten as we try to perform procedures in a minimally invasive manner. If the patient’s anatomy has not been adequately restored, however, the goal has not been attained, no matter how small the incision.
Generally, surgical procedures tend to be more effective if they restore or reproduce the anatomy of the joint as it was prior to the disease process. This is also true of rotator cuff repair. Success rates in rotator cuff surgeries are higher in patients with intact repairs. Recent studies with magnetic resonance imaging (MRI) or ultrasound have shown arthroscopic repairs to be intact 83 percent of the time at 1 year. Even though patients may get relief without an intact repair, the primary objective is to heal the rotator cuff repair. To optimize healing of the repair, the surgeon should address two major areas of the repair—stability and protection.
Visualization is just as important arthroscopically as it is in the open procedure. The surgeon must first establish a view and a space in which to work. Thorough bursectomy is crucial and may be facilitated by using an electrocautery device. Because the bursa is generally very vascular, débridement with a shaver may cloud the field.
Blunt separation of the bursa with the wand in the off setting can help define this plane prior to cauterization. Rotating the arm is helpful in differentiating between bursa and cuff.
Inserting a cannula through an unused portal enables the surgeon to manage fluids and facilitates visualization. If the operative field becomes cloudy, the surgeon may open the cannula to divert the bleeding away from the operative field until the source of the bleeding can be located and coagulated. Keeping fluid inflow to a minimum is helpful to reduce swelling of the shoulder.
The surgeon must prioritize procedures during the surgery, before swelling affects space and soft-tissue mobility. The more difficult rotator cuff repair should be done prior to decompression or distal clavicular excision.
The quality of repair may also dictate whether an acromioplasty should be performed, because a failed repair may produce superior escape with disruption of the superior arch structures. Some evidence exists that repair without decompression does not affect outcomes. If labral repair is required as well, it is generally easier to perform prior to the rotator cuff repair. The surgeon must use clinical judgment to ascertain which problems are symptomatic and to determine whether and in what order the pathology should be corrected.
The security of the repair is affected by the quality of the fixation and by the tension on the repair. The nature of the tendon can have an impact on the strength of a repair. If the tendon has the consistency of “wet tissue,” the repair may not be as trustworthy as if the tendon resembles “shoe leather.” Although the nature of the tendon is beyond the surgeon’s control, he or she can elect nonsurgical treatment in patients who are suspected of having poor tissue (as evidenced by muscle belly atrophy on MRI scans or by chronic retracted tears).
Using more fixation points in the tissue (additional anchors or additional sutures within the suture anchor [double- or triple-loaded anchors]) may improve the quality of the repair. Triple-loaded anchors have been shown to produce a more secure repair than single- or double-loaded anchors.
Either a single- or double-row construct may be used for additional anchors. The double-row construct increases the security of the repair and also may increase the contact area of the rotator cuff to the bone. It also increases the complexity of the repair, because medial anchors are more difficult to place and the sutures are more difficult to manage and pass. Having sutures from the medial row exit from a different portal than those from the lateral row may be helpful. Medial row sutures may also be secured to the lateral row anchors with knotless lateral anchors or by tying the medial and lateral sutures together, making sure to “complete the loop” and ensuring that both limbs of the suture are secured. This compresses the cuff repair between the two rows of anchors as well, increasing bone contact.
The bone contact area may be increased in single-row constructs as well, by using mattress sutures, by alternating mattress and simple sutures, and by varying the distance of suture passage medially from the anchor.
Increasing the number of anchors also provides more fixation points and can provide a “smoother” repair because multiple sutures converging at a single point can bunch the cuff at the repair site. Thorough, complete exposure of the greater tuberosity provides more surface area for anchor insertion, facilitating multiple anchor points. With more fixation points, the load sent to each point decreases, providing increased sharing of the repair tension.
An essential step of open repair that may be forgotten in the arthroscopic setting is the release. Releasing the bursal and articular surfaces of the tendon by incising capsular and acromial adhesions increases tendon excursion. If necessary, “side-to-side” releases may also be performed by incising the rotator interval anteriorly and the interval between supraspinatus and infraspinatus. (This is somewhat arbitrary because they overlap, but the scapular spine is the landmark).
Converging the repair to the insertion with side-to-side sutures also reduces tension on the repair. Any tear with a longitudinal or cavernous defect (U- or L-shaped) may benefit from this technique. Use a lateral portal to view the tear pattern.
Recruit and gather the tissue from the anterior and posterior aspects of the cuff superiorly and laterally when using side-to-side sutures. This repair will probably not increase muscular strength, but may help cushion the humeral-acromial interface and help restore force coupling of the rotator cuff. In partial-thickness tears, side-to-side repair may be performed with or without suture anchors (with transtendinous insertion), or by using the techniques previously described after detaching the intact portion. Roughen the proposed cuff insertion site as you would in an open procedure, but with a shaver.
Protecting the repair
Because arthroscopic repair involves less tissue trauma than open repair, stiffness is less likely to develop. Thus, passive motion therapy can begin at 2 weeks. If you suspect stiffness preoperatively, begin passive motion immediately. Initiate strength training at 12 weeks, but prohibit active elevation for at least 8 weeks.
At every visit, remind the patient, “No active elevation for 8 weeks.” Because pain diminishes more quickly with arthroscopic surgery, some patients may believe that everything is “OK” and begin using the arm prematurely. This common cause of early rupture is avoidable. Full activities are allowed at 6 months.
Arthroscopic rotator cuff repair is becoming a better option for patients. Despite early reports of failure of repair integrity, results are improving as the procedure is refined. Repair integrity will approach—but likely not exceed—rates of open repair; however, pain, motion, and function levels may approximate those of open repair. Remember, even though the procedure is done arthroscopically, the problem and the healing time are the same.
Robert M. Titelman, MD, is a shoulder-and-elbow surgeon in Atlanta. He can be reached at firstname.lastname@example.org Disclosure information for Dr. Titelman can be found online at www.aaos.org/disclosure.